C09999099 / invoice 10000

Reason: Possible Spinal - LmHISTORY:Bizmarck presented with acute onset left hind limb lameness during routine walk. Owner reports normal walking for first 200m, then noticed slowing down followed by limping. No specific trauma or incident noted. Owner reports generalised reluctance to walk over past three weeks with increased stiffness when rising from bed. Notes left side has always appeared problematic during running with body swaying to that side. Occasional transient limping episodes in past but nothing chronic.Owner able to massage and stretch legs at home without pain response, though notes left side feels less tense than right side.Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentioned  Pre-existing conditions: noneAccess to toxins eg. Rodenticide: noneEXAMINATION:Cardiovascular: no murmur noted Respiratory: wnlNeurological: proprioception normal in both hind limbs, no spinal pain detectedMusculoskeletal: severe pain response when examining left hind limb with patient attempting to bite when leg palpated, no spinal pain on palpationGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): not graded- Abdominal: not performed- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: reactive and defensive when left hind limb examined, otherwise cooperative for spinal examinationPROBLEM LIST:Acute onset left hind limb lameness with severe localised painThree week history of exercise intolerance and generalised stiffnessChronic left-sided gait abnormalityDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Suspected cranial cruciate ligament rupture left stiflePossible luxating patellaPossible partial cruciate ligament tear with chronic progressionDIAGNOSTICS:NoneASSESSMENT:Bizmarck presented with acute onset severe left hind limb lameness during routine exercise. Clinical examination reveals significant pain localised to left hind limb with patient becoming defensive when area examined. Neurological assessment normal with intact proprioception and no spinal pain, ruling out spinal pathology. History of chronic exercise intolerance and left-sided gait abnormality suggests possible pre-existing partial cruciate ligament damage with acute progression to complete rupture. High index of suspicion for cranial cruciate ligament rupture given acute presentation, localised pain, and breed predisposition.TREATMENT:Meloxicam prescribed for pain relief trial over weekend - dose to 19kg bodyweight mark on syringe, once daily with food. Discontinue if vomiting or diarrhoea occurs.Strict rest advised - no walks, no jumping on furniture, no stairs.0.3mg/kg methadone on arrivalPLAN:Pain relief trial for 3-4 daysAppointment booked with regular vet for Monday for further assessmentRadiographs recommended if lameness persists after pain relief trialTransfer to Primary VetCLIENT COMMUNICATION:Discussed suspected cruciate ligament rupture and degenerative nature of condition. Explained 90% chance of bilateral involvement if diagnosis confirmed. Discussed TPLO surgical procedure as treatment option if cruciate rupture confirmed. Advised that delayed treatment leads to secondary arthritis formation. Emphasised importance of strict rest to prevent further damage. History forwarded to regular veterinarian for Monday appointment.--- 02/03/2026 21:24:46 PM PED:Treatment - Resolved - follow up text sent DOP    Vital Signs    Weight: 19.9;